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3 UNITED NATIONS INTERNATIONAL DRUG CONTROL PROGRAMME VIENNA Investing in Drug Abuse Treatment A Discussion Paper For Policy Makers UNITED NATIONS New York, 2003

4 The present discussion paper was commissioned by the United Nations International Drug Control Programme (UNDCP). Gratitude is expressed to A. Thomas McLellan, Treatment Research Institute, University of Pennsylvania/Veterans Administration Center for Studies of Addiction, United States of America, who wrote the discussion paper (and whose work is supported by the National Institute on Drug Abuse, the Center for Substance Abuse Treatment, the Office of National Drug Control Policy, the Department of Veterans Affairs and the Robert Wood Johnson Foundation); to Robert Ali, Drug and Alcohol Services Council, Adelaide, South Australia, Australia, and Manit Srisurapanont, Department of Psychiatry, Chiang Mai University, Thailand, who both provided valuable feedback; and to the drug demand reduction experts and focal points at the UNDCP regional and country offices, who kindly provided feedback and helped bring a multicultural perspective into the discussion paper. The Office for Drug Control and Crime Prevention became the Office on Drugs and Crime on 1 October The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

5 Summary Drug addiction produces serious, pervasive and expensive social problems. Regardless of whether substance abuse is a sin, a crime, a bad habit or an illness, society has a right to expect that an effective public policy or approach to the drug abuse problem will reduce drug-related crime, unemployment, family dysfunction and disproportionate use of medical care. Science has made great progress over the past several years, but it is still not possible to account fully for the physiological and psychological processes that transform controlled, voluntary use of alcohol and/or other drugs into uncontrolled, involuntary dependence on those substances, and there is still no cure. What can be done is to treat use effectively and to provide an attractive return on societal investment in treatment. Controlled clinical trials and large-scale field studies have shown statistically and clinically significant improvements in drug use and in the drug-related health and social problems of treated individuals. Further, those improvements translate into substantial reductions in social problems and costs to society. The present paper compares the effectiveness of various forms of treatment with non-treatment alternatives such as no treatment at all and criminal justice interventions. In each case, the research evidence suggests that treatment interventions are more effective than non-treatment. An effective public policy or approach to the drug abuse problem will reduce drug-related crime, unemployment, family dysfunction and disproportionate use of medical care. The main phases of substance abuse treatment are detoxification/stabilization, rehabilitation and continuing care. The published scientific literature provides evidence of effective treatment components with the length of stay being the clearest predictor of beneficial effects from treatment. Treatment modalities with longer recommended duration typically have better outcomes, as do patients who remain engaged in treatment longer, regardless of the modality. The research evidence is clear that, for those with severe forms of drug dependence, the best available treatments are: Ongoing, like treatments for other chronic illnesses; Able to address the multiple problems that are risks for relapse such as medical and psychiatric symptoms and social instability; Well integrated into society to permit ready access for monitoring purposes and to forestall relapse. Importantly, the research shows that while motivation for treatment plays an important role in maintaining treatment participation, most substance-abusing patients enter treatment with combinations of internal motivation and family, employment or legal pressure. Those pressures can be combined with treatment interventions for the benefit of the patient and society. The evidence is compelling that, at the present state of knowledge, addiction is best considered a chronic relapsing condition. It is true that not all cases of addiction are chronic and some who meet diagnostic criteria for substance dependence recover completely without treatment. However, many of those who develop addiction disor- iii

6 Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers ders suffer multiple relapses following treatments and are thought to retain a continuing vulnerability to relapse for years or perhaps a lifetime. Like so many other illnesses, it is impossible to predict whether or when an acute care strategy is likely to achieve complete remission. For example, while change in diet, exercise and lifestyle can reduce high blood pressure in some patients without medication or continuing treatment, many others require sustained management with medications as well as regular monitoring of diet, stress and exercise. In considering addiction a chronic condition, it is no longer surprising that incarcerations or brief stabilizations are not effective. The available research is quite clear on these points: Drug abuse is best treated by combinations of continuing outpatient therapy, medications and monitoring. Education does not correct drug dependence: it is not simply a problem of lack of knowledge. Consequences of drug use (e.g. hangovers, loss of job, arrest, etc.) appear to be important stimuli leading to entry into drug abuse treatment. Very few addicted individuals are able to profit from a corrections-oriented approach by itself. Relapse rates are over 70 per cent from all forms of criminal justice interventions. Addiction is not simply a matter of becoming stabilized and getting the drugs out of one s system. Relapse rates following detoxifications are approximately the same as those following incarceration. Based on these findings, drug abuse is best treated by combinations of continuing outpatient therapy, medications and monitoring, with the goal of retaining drug abusers in that treatment/monitoring regimen to maximize and maintain the full benefits of treatment. Recent pharmaceutical research has produced effective medications for the treatment of alcohol, nicotine and opiate dependence and has identified promising candidate medications that will provide even more assistance to physicians in treating those illnesses. From this, one must conclude that drug and alcohol dependence are treatable medical illnesses. While this paper compares addiction to other chronic illnesses, there are many differences. One of the most prominent differences is the impact of the disease on the family and society. The major focuses of most treatments for other chronic illnesses are symptom remission and return of function for the benefit of the patient. This has also been true for many addiction treatments, which has left much of society with the view that the major goal of addiction treatment is simply to make the patient feel better-not something those who have suffered from the crime, lost productivity and embarrassment of addiction are eager to do. The perspective taken here suggests that addiction treatment providers must broaden their responsibilities and focus on such socially important goals as: Working with employers and social welfare agencies towards the goals of returning to or finding work; Working with criminal justice agencies and parole/probation officers towards the goals of keeping the patient from returning to drug-related crime and incarceration; Working with family agencies and families towards the goals of returning to, or taking on, responsible family roles, especially parenting. iv

7 Executive summary These are the addiction-related conditions that most affect society and reduction or elimination of them are what society expects from any effective intervention. This paper concludes that substance abuse treatments can and should be expected to improve the public health and social problems of patients and that there are methods of organizing the structure and delivery of care to achieve those outcomes. Substance abuse treatments can and should be expected to improve the public health and social problems of patients. v

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9 CONTENTS SUMMARY iii INTRODUCTION 1 1. WHAT WOULD MAKE AN INTERVENTION SOCIALLY WORTHWHILE? SOCIETY'S EXPECTATIONS FOR "EFFECTIVE" INTERVENTIONS 5 What brings substance abusers to treatment? 5 What outcomes are expected from substance abuse treatment? 6 Outcome domains based on public expectations 9 2. NON-TREATMENT ALTERNATIVES TO ADDRESS SUBSTANCE ABUSE 13 Evidence for treatment effectiveness 13 What happens if substance abuse is not treated? 13 Non-treatment interventions for substance abuse 17 Combining treatment and non-treatment interventions for substance abuse WHAT COMPRISES CONTEMPORARY ADDICTION TREATMENT? 23 What components contribute to treatment effectiveness? 23 Phases of treatment 23 Patient and treatment factors shown to be important in determining outcome WHY ARE ADDICTION TREATMENTS NOT AS EFFECTIVE AS TREATMENTS FOR OTHER ILLNESSES? 29 Implications for the delivery and evaluation of addiction treatment 29 Compliance, symptom remission and relapse in addiction treatment 29 Compliance, symptom remission and relapse in the treatment of chronic illnesses 30 A chronic illness perspective on treatment and evaluation designs 31 vii

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11 Introduction Problems of substance dependence produce dramatic costs to all societies in terms of lost productivity, transmission of infectious diseases, family and social disorder, crime and, of course, excessive utilization of health care. These alcohol- and drug-related problems not only reduce the safety and quality of daily life, they are also a source of substantial expense. For example, it has been estimated that, in the United States of America, the total cost of alcohol abuse in 1990 was 99 billion United States dollars and drug abuse cost approximately US$ 67 billion, while the total cost of illicit drug abuse in Australia was estimated to be 1,684 million Australian dollars (or US$ 1,237 million) in In Canada, the total cost of alcohol abuse in 1992 was estimated to be 7,522 million Canadian dollars (US$ 6,223 million) and the total cost of illicit drug abuse Can$ 1,371 million (US$ 1,134). Understandably, such problems also produce heated debates regarding what a family, a school, an employer, a Government and/or a society should do to reduce the costs and the threats of substance abuse to the public health and safety of citizens. Alcohol- and drugrelated problems not only reduce the safety and quality of daily life, they are also a source of substantial expense. There are few countries regardless of their economic development with a well developed public treatment system designed to address different substances of abuse and different levels or manifestations of the addiction spectrum. Why have treatment options not been more favourably considered and better developed and disseminated to address the problems of substance dependence? Perhaps the first reason for this is the relative prominence of the social problems caused by drug and alcohol abuse. Crime, family disruption, loss of economic productivity and social decay are the most observable, potentially dangerous and expensive effects of drugs on the social systems of most countries. This is a powerful factor in shaping the general view that the drug issue is primarily a criminal problem requiring a social-judicial remedy rather than a health problem requiring prevention and treatment. A second reason for a diminished role of treatment in most public policies regarding drug abuse is that most societies are sceptical about the effectiveness of substance abuse treatments and most Governments question whether treatment is worth it. Moreover, recent surveys show that even a majority of general practice physicians and nurses feel that the currently available medical or health-care interventions are not appropriate or effective in treating addiction. A third reason why treatment options may not have received more attention in public policies regarding drug abuse is the pervasive view that a treatment approach to substance abuse conveys an implicit message that the addiction and the addictionrelated problems are not the fault of the addicted person; that they can't help themselves and that they have no responsibility for the actions that led to or resulted from the addiction. In that regard, the view exists that treatments are designed exclusively to help the drug user but not society. Why should a society expend resources to help an individual who may have produced social harms? These are messages that many people find offensive and unfair. 1

12 Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers Is there a role for addiction treatment in public policy aimed at reducing drug-related problems? Thus, treatment interventions that admittedly cannot cure addiction and that may be seen as focused only on helping socially stigmatized addicted individuals are not popular in many segments of society. Are those perceptions correct? Is there a role for addiction treatment in public policy aimed at reducing drug-related problems? In the text that follows the issue is considered from several perspectives. The first part of the paper considers the perspective of a Government or public agency questioning the value of any intervention aimed at drug problems : What would an effective intervention do, regardless of whether the intervention were a punitive, criminal justice intervention, an educational intervention, a new social policy or a treatment intervention? Here the paper examines the characteristics of patients who enter addiction treatments asking where they have come from, who or what agency has referred them to treatment and what goals are expected by those agencies and organizations. This examination is used to develop a set of outcome expectations that would make treatment worth it to a society that might be asked to support such an intervention or policy. The second part of the paper uses these expectations and the outcome measures that derive from them as the operational definition of effectiveness. On the basis of that definition, some of the published research literature is reviewed examining the available evidence for the effectiveness of some of the more prominent forms of substance abuse treatment, comparing them with two common non-treatment policy alternatives for substance abuse no treatment at all and criminal justice interventions such as jail. Building upon the outcome expectations and empirical findings in the first two parts of the discussion paper, the third section presents an overview of how an appropriate and effective treatment system might be constructed. The attempt here is to present some of the generic issues facing the treatment of addiction, review some of the identified mechanisms of action among those forms of treatment that have been studied and, through that effort, offer suggestions for some of the active ingredients that are likely to be effective with a broad range of patient types. The final part of the paper addresses an important question for the policy maker: Why does it appear that addiction treatment is not as potent or as effective as treatments for other disorders? As the basis for that discussion the paper compares addiction treatments with treatments for three well-studied, chronic medical illnesses. The examination of the issue leads to particularly important conclusions regarding how addiction treatment is viewed by the public, how it is typically provided by treatment programmes and how it has been evaluated by researchers. 2

13 1 What would make an intervention socially worthwhile? Society s expectations for effective interventions

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15 1. What would make an intervention socially worthwhile? Society's expectations for effective interventions What brings substance abusers to treatment? General models of medical service utilization have been adapted to explain who will use substance abuse treatment. However, the assumptions underlying such experimental models of medical care utilization are often very different from the special circumstances affecting entry to substance abuse treatment. To an important extent, requests for general medical treatments come directly from the prospective patient and are governed by personal and structural factors such as the patient s perception of the severity of the primary medical condition, the patient's geographical and financial access to services and the patient s beliefs regarding the potential help or relief that will be received for those primary symptoms. The use of general medical services is thus typically a voluntary act and is rarely determined by any coercive relationship from a third party. In contrast to utilization of general medical interventions, referrals to substance abuse treatments often come from an organization, institution or family member who has become aware of the substance abuse indirectly through recognition of what is attributed to be an addiction-related social, family, financial, employment or medical problem. During the last decade, problems of crime, workplace safety and spread of various infectious diseases and even neonatal health have come to be considered addiction-related problems. Thus, organizations and agencies charged with addressing those societal problems have become very important determinants of substance abuse treatment utilization, initiating referrals based upon the extent to which they believe that: From most agencies perspectives the desires of the prospective patient are not primary. Thus many substance abuse treatment referrals are characterized by some degree of external coercion. An observed problem is attributable to substance abuse; Reduction of the substance abuse problem would be instrumental in producing desirable change in the observed problem; Substance abuse treatments can produce the desired reduction of the substance use and thereby the desired improvement in the related problem. Notice that from most agencies perspectives the desires of the prospective patient are not primary. Thus many substance abuse treatment referrals are characterized by some degree of external coercion, either through criminal justice system sentences or conditions of probation/parole, employer-mandates or social pressuring from family and community. In accordance with these societal, institutional and family pressures, substance abuse treatment has changed over time to accommodate changing levels of public concern about drug problems, as well as in political commitments to provide accessible services. These pressures are very important both to the prospective patient and to society, since they form the contract under which treatment is provided and evaluated. 5

16 Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers What outcomes are expected from substance abuse treatment? Primary health-care sources expect an effective treatment to reduce the serious medical and public health risks associated with substance use such as AIDS, hepatitis and tuberculosis. Many public and private service organizations, such as the welfare system, the criminal justice system, emergency rooms, orphanages, employee assistance programmes and family violence centres, come into contact with alcohol and drug abuse problems in the course of their responsibility for handling social, employment and health-care problems. These organizations often refer substance users from their caseloads to adjunctive substance abuse treatment as a means of dealing with these addiction-related problems. Such reasons for referral form many of the expectations regarding the desired goals of substance abuse treatment. For example, in many countries hospitals and other health-care agencies are major referral sources for substance abuse treatments. These primary healthcare sources expect an effective treatment for substance dependence to reduce the serious medical and public health risks associated with substance use such as acquired immunodeficiency syndrome (AIDS), hepatitis and tuberculosis, and to reduce the disproportionate utilization of primary health-care services that is so characteristic of alcohol- and/or drug-dependent individuals. Unemployment and welfare costs have been areas of public and policy concern in recent years. Those with alcohol and drug abuse problems among the welfare population may be referred to substance abuse treatment with the expectation that effective treatment will improve the vocational and employment prospects of their referrals. Indeed, these kinds of addiction-related treatment goals have been included in contracts between public service agencies and substance abuse treatment programmes that accept their referrals. Boxes 1 to 3 illustrate the social costs that substance abuse represents in different countries. Box 1 Costs of drug abuse in the United Kingdom of Great Britain and Northern Ireland According to results from a study released by the Home Office in February 2002, the annual economic costs of drug abuse in the United Kingdom are between 3.7 billion (or US$ 5.6 billion) and 6.8 billion (or US$10.3 billion). Most of these costs fall upon the criminal justice system as a result of drug-related criminality in the form of organized crime, burglaries and robberies and violence. Other social costs are borne by the health system (about 235 million (US$338 million) in 2001 on primary care services, accident and emergency admissions and drug abuse treatment), the workplace, schools and families (total social costs were estimated at 10.9 billion (US$16.5 billion) to 18.8 billion (US$28.4 billion)). It is estimated that 99 per cent of the costs are associated with problem drug abusers. As the study estimated that there are 280,000 problem drug users in the United Kingdom, each problem drug user could cost about 30,000 (US$45,000) a year. Source: United Kingdom of Great Britain and Northern Ireland, Home Office, "Drugs minister highlights savings in criminal justice: costs of drug treatment expenditure", press release, 12 February

17 Part 1 What would make an intervention socially worthwhile? Box 2 Social costs in Australia A study conducted in Australia estimated the total costs of illicit drug abuse in that country. The study concluded that total tangible costs amounted to 1,248 million Australian dollars (US$ 917 million) in The major components of these costs were net production costs (associated with mortality of morbidity of people of working age) and law enforcement. Source: D. J. Collins and H. M. Lapsley, The Social Costs of Drug Abuse in Australia in 1988 and 1992, National Drug Strategy Monograph Series (Canberra, Australian Government Publishing Service, 1996). Box 3 Social costs of drug abuse in Brazil In order to estimate costs resulting from drug and alcohol abuse, research in Brazil has concentrated on medical treatment, loss of productivity at work and the social loss resulting from premature deaths. According to the Ministry of Health of Brazil, costs resulting from drug-related productivity losses and premature deaths in Brazil correspond to 7.9 per cent of the gross national product, equivalent to US$ 28 billion. a Costs resulting from drug-related productivity losses and premature deaths in Brazil correspond to 7.9 per cent of the gross national product. Between 1995 and 1997, hospitalization costs associated with psychoactive substance use added up to 601,540, reaís (currently equivalent to US$ 250 million). Hospitalization causes included traffic accidents, cardiac insufficiency, cancer and suicide attempts. a The number of accumulated acquired immunodeficiency syndrome (AIDS) cases in Brazil in June 2001 was 215,810. According to the Ministry of Health, 25 per cent of registered AIDS cases are injecting drug-related (intravenous drug users (IDU), their partners and children) and 14 per cent are due specifically to needle- sharing. b In addition, 38.2 per cent of AIDS-infected women were IDUs or had IDU partners and 36 per cent of children with AIDS had an IDU mother or mother's partner. Mental disorders related to use and abuse of psychoactive substances were the second cause of psychiatric hospitalizations and were among the top 5 causes of all hospitalizations in the country. Between 1993 and 1997, almost 1 million hospital admissions were a result of alcohol- and drug-related psychosis. a Studies carried out by the Brazilian Centre for Information on Psychotropic Drugs (CEBRID) in several Brazilian cities in 1989 and 1993 revealed that up to 90 per cent of the children and adolescents who live on the streets use drugs. This figure was lowest in Rio de Janeiro, where rates were still above 50 per cent. c A study carried out by the São Paulo State Federation of Industries (FIESP) on drug abuse and alcohol dependence problems in the workplace pointed out that 10 to 15 per cent of employees present addiction problems and that such problems: d Are responsible for three times more sick leaves than other diseases; Are responsible for 50 per cent of absenteeism; Increase five times the chances of accidents in the workplace; Are involved in 15 to 30 per cent of all work-related accidents; Lead to eight times the hospital costs; Lead families to use three times more social and medical insurance. 7

18 Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers Box 3 continued Current statistics in the United States indicate that as many as 60 per cent of federal prisoners meet diagnostic criteria for a substance dependence disorder. Recent research e showed that 80 per cent of prisoners have had problematic use of legal or illegal drugs. According to the national seminar on sexually transmitted diseases and AIDS prevention and drug use in prisons, held in Brasilia on 16 and 17 December 1999, in many states throughout Brazil the sharing of injectable drugs is the main form of transmission of the human immunodeficiency virus among prisoners. a Brazil, Ministry of Health, mental health site: b Ministry of Health/Federal University of Minas Gerais, Brazil, AJUDE-Brasil II Project, 2002, unpublished data. c A. R. Noto and others, III Levantamento sobre o uso de drogas entre meninos e meninas em situação de rua de cinco capitais brasileiras (Centro Brasileiro de Informações sobre Drogas Psicotrópicás, 1993). d Magda Waismann, doctoral thesis, Federação e Centro dos Indústrias do Estado de São Paulo, e Departamento Geral do Sistema Penitenciário, Secretaria de Estado de Direitos Humanos e Sistema Penitenciário, Rio de Janeiro, The costs of substance abuse in the workplace have also been emphasized during the past decade and a growing number of employers have initiated programmes run by management or employee unions designed to detect substance abusers in the workforce and to refer them to treatment programmes. These employers and unions are typically most interested in the return of affected employees to a high level of work performance following treatment and an assurance for co-workers that they will not be put in danger. Finally, most societies are worried about crime. Current statistics in the United States indicate that as many as 60 per cent of federal prisoners meet diagnostic criteria for a substance dependence disorder. The statistics on street crime in that country suggest that as many as 50 per cent of all property crimes are committed under the influence of alcohol and/or drugs or with the intent to obtain alcohol and/or drugs with the crime proceeds. The concern for public safety and the awareness of the relationships between crime and substance abuse have pushed the criminal justice system to consider treatment alternatives to incarceration for drug-related crimes. Thus, police, probation/parole officers, judges and other agents of the criminal justice system have become major sources of referral to substance abuse treatments. For them, the effectiveness of substance dependence treatment is measured by reductions in crime, parole/probation violations and incarceration rates among affected individuals. Box 4 illustrates the consequences of drug abuse on the criminal justice system. In summary, there has been a very clear expectation among most of society that effective substance abuse treatment should do more than simply produce abstinence: it should also address costly and socially damaging addiction-related problems. 8

19 Part 1 What would make an intervention socially worthwhile? Box 4 Drug abuse and possession in the criminal justice system in Mauritius As at mid-february 2002, statistical returns from the Commissioner of Prisons in Mauritius indicate the following: (a) Some 706 out of a total 1,264 inmates (or 56 per cent) were drugrelated cases. Of those 706 drug detainees, 513 (or 73 per cent) had been convicted for drug abuse/possession and the remainder for selling, trafficking and cultivation; (b) The number of detainees awaiting trial in prisons for drug cases was 474 (or 51 per cent), out of a total of 921 detainees in this situation. Of the 474 detainees awaiting trial in prisons for drug cases, 352 (or 74 per cent) were there for abuse/possession. The data above indicate that a proportionally enormous amount of resources are required to deal with drug abuse and possession at the police, judicial and prison levels. Investing in culturally appropriate treatment would help reduce such costs in addition to reducing associated human suffering. Source: Mauritius, Ministry of Social Security and Reform Institutions. Effective substance abuse treatment should do more than simply produce abstinence: it should also address costly and socially damaging addictionrelated problems. Outcome domains based on public expectations Based upon the above discussion it is reasonable to consider three outcome domains that are relevant both to the rehabilitative goals of the patient and to the public health and safety goals of society: (a) Elimination or reduction of alcohol and illicit drug use. This is the foremost goal of all substance abuse treatments; (b) Improved personal health and social function. Improvements in the medical and psychiatric health, as well as the social function, of substance-abusing patients are clearly important from a societal perspective but, in addition, improvements in those areas are also related to prevention of relapse to substance abuse; (c) Reduction in public health and public safety threats. The threats to public health and safety from substance-abusing individuals come from behaviours that spread infectious diseases and from behaviours associated with personal and property crimes. Specifically, the sharing of needles and trading sex for drugs are significant threats to public health. The commission of personal and property crimes for the purpose of obtaining drugs and the dangerous use of automobiles or equipment under the influence of alcohol are examples of major threats to public safety. In the review that follows these three outcome domains have been used to assess the effectiveness of substance abuse treatment programmes and treatment components. In addition, the essential consideration would evidently be cost and cost-effectiveness of interventions when investing in treatment. Box 5 illustrates economic benefits of drug abuse treatment and figure I shows costs of different approaches in the United States. 9

20 Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers Box 5 Social benefits of drug abuse treatment in the United States Every US$1 invested in treatment reduces the costs of drug-related crime, criminal justice costs and theft by US$4-7. Widespread availability of and easy access to treatment has broad social benefits. Every US$1 invested in treatment reduces the costs of drug-related crime, criminal justice costs and theft by US$4-$7. When health-care savings are added in, total estimated savings can exceed costs by a ratio of 12 to 1. By helping people reduce or stop injecting drugs, substance abuse treatment reduces the transmission of blood-borne diseases, such as HIV, hepatitis B and hepatitis C. Treatment can also improve the stability of family and community life and improve a person's prospects for employment. Source: United States of America, Department of Health and Human Services, Centers for Disease Control, Policy Issues and Challenges in Substance Abuse Treatment, 2002 (see Figure I Costs of drug abuse treatment in the USA per person, per year (United States dollars) Outpatient treatment a (cocaine) Methadone maintenance b (heroin) Residential treatment a (cocaine) Probation c Incarceration d Untreated addiction d United States dollars a 1992 figures. The average cost per admission is much lower than these figures because most patients are in treatment less than one year. b 1993 figures. c 1992 figures, adjusted for inflation from 1983 data. d 1991 figures. Source: Institute of Medicine, Pathways of Addiction: Opportunities in Drug Abuse Research (Washington, D.C., National Academy Press, 1996), p. 199, figure 8.1 (adapted). 10

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